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How Effective Are Breast Feeding Policies?

Breast feeding has been rather consistently associated with a lower risk of childhood obesity (and better post-partum weight loss in mothers).

Unfortunately, what was well intended by mother nature has long been widely abandoned (or shortened) to suit our rather unnatural lifestyles.

Is this a trend that can be reversed?

A paper by Sara Kirk and colleagues from the University of Dalhousie, Halifax, now examine the lessons learned from the implementation of a provincial breastfeeding policy in Nova Scotia and the possible implications for childhood obesity prevention, in the International Journal of Environmental and Public Health.

In recognition of breastfeeding as the optimal mode for infant feeding and a critical factor in promoting infant health, in 2005, the Canadian province of Nova Scotia introduced a provincial breastfeeding policy.

The policy applies to the provincial government Department of Health and Wellness, District Health Authorities and all health system funded providers. The policy comprises ten directives designed to promote breastfeeding initiation and duration in Nova Scotia and to provide supportive environments for breastfeeding mothers. These directives include the need for leadership and support for breastfeeding throughout the province, along with monitoring and evaluation of the policy.

For their study, the researchers conducted focus groups with members of provincial and district level breastfeeding committees who were tasked with promoting, protecting and supporting breastfeeding in their districts.

These discussions revealed five comon themes that posed barriers to the full implementation of this policy: an unsupportive culture of breastfeeding; the need for strong leadership; the challenges in engaging physicians in dialogue around breastfeeding; lack of understanding around the International Code of Marketing of Breast-milk Substitutes; and breastfeeding as a way to address childhood obesity.

Of these, the most pervasive and consistent barrier was that faced by mothers in a culture that is generally unsupportive of breast feeding. As the authors note:

“This unsupportive culture of breastfeeding was viewed as a barrier to breastfeeding across the continuum of care, but most especially beyond six months, or when women returned to work. Specifically, the perceived lack of a supportive environment was reflected in participants’ anecdotal accounts of breastfeeding, both in the workplace and in the broader community. While participants felt that breastfeeding mothers were philosophically supported to breastfeed when they returned to work, the practical reality of needing to pump or breastfeed at work was not seen as particularly well supported.”

This unsupportive culture was clearly evident from some of the quotes in the article:

“I tried with my first [baby] pumping when I came back and it did not work because…when there’s work to be done, people don’t look real friendly at you if you’re running off with a pump and you’re doubling up work for somebody else while you’re gone, so if you actually get a break you could run and do it…”

“…and this isn’t being judgmental either but there’s not one staff member in our facility that smokes that does not get three or four extra smoke breaks during the day and they don’t take those on their lunch breaks and their coffee breaks, they’re never questioned when they want to go out for a smoke…but granted, it doesn’t take as long to have your cigarette as it does to nurse a baby, but it’s just the whole thought process around it, like people don’t view that as a hindrance to your working life as much as they would to sneak off and feed baby”

“We’ve got to change the minds, the culture has to change because even nursing at 22 months I was getting to the point, and I know I shouldn’t have been, but to the point where I felt I had to hide it. I had to hide it from my mother because she’d say ‘oh my god you’re too old to be breastfeeding this child’, or ‘she’s too old to be breastfeeding’, but you get to the point where you feel you have to hide it because it’s not normal, it’s not considered normal to others”

This is not to say that the other themes were likewise relevant.

However, cultural acceptance of breast feeding (in public) is something that appears to be completely lacking in North America. While back in Europe, no mother would think twice about laying bare her breast to feed her infant in public (and no one would consider this anything but completely normal), it is almost hilarious to note the ridiculous fuss that people here in Canada seem to make about this.

In Europe, where parents are slightly embarrassed to be seen offering their kids a bottle in public, the opposite is true. But things are changing there too – and not for the better.

Thus, although the authors note that

“…promotion of breastfeeding offers a population-based strategy for addressing the childhood obesity epidemic and should form a core component of any broader strategies or policies for childhood obesity prevention.”,

I am less than optimistic that we will see widespread movements to breast feed infants for as long as nature intended. Unfortunately, policies cannot change culture – rather, changes in culture change policies.

I’d certainly like to hear my readers’ views on this issue. What are the perceived barriers to breast feeding and how do you think they could be addressed?

Edmonton, Alberta

ResearchBlogging.orgKirk SF, Sim SM, Hemmens E, & Price SL (2012). Lessons learned from the implementation of a provincial breastfeeding policy in nova scotia, Canada and the implications for childhood obesity prevention. International journal of environmental research and public health, 9 (4), 1308-18 PMID: 22690194



  1. The one year maternity leaves in Canada really helps rates here compared to the 3-6 weeks in the states. However for many jobs such as self employed moms they do not have paid maternity leaves and have to return to work much sooner which makes breast feeding a challenge. Having some sort of paid coverage for these moms would be very helpful.

    From my own experience pumping requires a solid 15 minutes with the set up and clean up involved, and twice a day in an 8 hour time frame is required to maintain a good milk supply. You have to do the cleaning every night and remember to bring the parts back every day. If you are delayed at all from pumping during your work day you get uncomfortable so it works best with jobs that have regular consistent break times. The pump makes a bit of noise so it is ideal to have more of a sound proof room where you can be sure no one could walk in. I used to put a chair in front of my office door to make sure the cleaners wouldn’t walk in. So there are many reasons why it is hard to keep up over a longer time frame.

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  2. From a health care professional: I see that the main barrier is the lack of support from the Medical community. Most drs that I work with (GP’s) as soon as they see any struggle with breast feeding they jump an begin with formula.
    I was able to breast feed my 3 kids for 12 months, even as a working mom and I have to say that it is one of the most regarding experience that I have ever had.
    Public health programs should be focusing on the positive of breast milk and breast feeding in all levels of the population: moms, dads, grand parents, coworkers, family members and also children

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  3. After reading Claire’s comment I would like to add that pediatricians may feel it is important to have all babies grow right along a growth curve. I know several friends who were told their baby wasn’t growing well enough just on their breast milk and they were asked to supplement with formula. Anyone who has tried to do both breast and bottle feeding at the same time will quickly realize it is difficult to sustain for long as it takes a great deal of time and energy and this will not help the mom’s milk supply. Doctors could be more accepting of some individual variation in weight gain before a breast feeding mom is asked to supplement with formula, as this may be the beginning of the end for the breast feeding.

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  4. I have been breastfeeding and working close to full time for over a year (here in the United States.) I think it is hard to fully verbalize the challenges of breastfeeding. I would agree 100% with the statement that breastfeeding is not considered normal. In my opinion, while everyone knows that you should breastfeed this goes in the same “great but impractical” category as say milling one’s own flour. For me, I have found the need to constantly physically tethered to a pump (manual or electric) or baby every 3-4 hrs, every single day very difficult. I think even the most dedicated person begins to feel claustrophobic and constrained. Right now I would estimate I spend a minimum of four hours per day nursing or pumping (six is not unusual at all.) Of course everyone is different and times will vary, but I think the time you devote to breastfeeding can be quite significant. Most women have to find a way to make this kind of time – and of course this requires sacrifice (usually of sleep and very rare personal time.) I think pumping and breastfeeding is the easiest to maintain when you have a set routine and schedule. The thing is, to pump you have to have a plan – where am I going to pump? Is there a power outlet, if not will I use a manual pump? Is there a place to store my milk or will I need to carry my pump and milk around with me all day? Or should I just pump and throw out the milk just to keep my supply up? It takes me a minimum of 15-25 minutes to pump. Just last week I was in work related training for three days that only provided 10min breaks. I had to make the decision to use a manual pump in a bathroom stall, and then walk in to class 10min late after each break. My pump managed to malfunction and the bottle portion that holds the milk literally dropped off spontaneously, spilling milk all over me and all over the bathroom floor. This situation is not common but not that unusual either. You really have to go to great lengths to avoid tipping bottles over and making sure everything is screwed on tight.
    From a technical point of view, breastfeeding and pumping is not explained sufficiently. Too many women do not understand your milk supply is built up by a constant cycle of supply and demand (in the first few months, supply can be hormonally determined but again each woman will produce a different amount naturally from too little to too much.) Every breastfeeding (or pumping) woman will question if she produces enough milk. These thoughts run through your head constantly. Most women are told if they do not make enough milk to supplement with formula. My issue with this is, how are we defining not enough? I think in many cases this is a perception of inadequacy not a real literal lack of milk. However, say you really did need to boost your supply – this would require you to nurse consistently to the point of emptiness and then a little past in order to stimulate your body to produce more. If you haven’t pumped some surplus milk (I used to wake up in the middle of the night to do this) to offer to your child if they are crying from hunger, then who wouldn’t turn to formula? And then once you do this, wouldn’t it be tempting to not spend an extra 10-15min nursing to emptiness and beyond? Becoming partially and then maybe fully reliant on formula is pretty logical given the circumstances of being tired, busy, and worried about your baby going hungry.

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  5. I agree with Erin regarding growth patterns. I live in a progressive urban area and so our doctor is aware that breastfeed babies grow at different rates. At the same time, they still offer little comments like “breastfeed babies frequently lack iron.” This presents two conflicting viewpoints – either breastfeeding is best or breastfeeding is insufficient – which is it?

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  6. Occasionally, I watch “A Baby Story” on TLC. I have noticed that almost none of the new mothers breastfeed their children. It makes me want to scream. I really don’t think that breastfeeding is looked upon as normal in North America.

    (I breastfed both my children. I breastfed my first child for eight months, until I had to go on thyroid medication, at which point I was forced to wean him. I breastfed my second son for nine months and then he weaned himself. Different strokes for different folks.)

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  7. I breast fed my son for almost two years, and I stopped because the doctor told me that he was not gaining weight fast enough. The doctor said I should switch him to homogenized milk, so I did. At first I resisted the change and kept breastfeeding, but after a second visit to the doctor where he noted the same lack of adequate weight gain, I made the switch. I have no idea if his weight really was a concern or not. Maybe breastfed babies just grow more slowly. I did find that some people thought the 20 months that I breastfed was “too long,” including some of my relatives. I don’t know if it was related or not, but my son did not need to take antibiotics until he was 8 years old, and he is rarely sick.

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  8. I live in Prince Edward Island and as a mommy who chose to not breastfeed I felt very isolated in my decision. From my perspective the medical community and fellow mothers here on the Island are very much committed to fostering a breastfeeding culture.

    I did a great deal of research and put a lot of time and thought before making my decision to not breastfeed. My decision was made based on two key reasons 1) my husband and I only have each other, both of our families live away and we had very few friends at the time we had our first born and I was worried that I would not have the emotional support required to breastfeed successfully. 2) I was concerned with the “nutritional quality” of my breastmilk versus the nutrients found in formula. I know my eating habits, I have always suffered from low iron, my ability to fight off infections is non-existent, so I really couldn’t see what benefit my son would be getting from me that he wouldn’t get from a nutrient rich, iron fortified formula.

    I am the first to encourage my friends to breastfeed and acknowledge the theory that “breast is best” but I don’t not agree that is indeed the case 100% of the time. Case in point, I delivered twin girls at 35.5 weeks, each weighing a very healthy 5lbs 10oz at birth and they spent 10 days in the NICU and I placed them on Good Start formula right away. A young mother delivered a baby 4 weeks early and she made the decision to breastfeed her baby. Everyday during our time in the NICU that young mother would step outside periodically to have a smoke, she ate Mcdonalds for every meal including a large Diet Coke.

    I strongly believe that if researchers were able to assess the nutritional value of her breastmilk versus that of Good Start formula, I can’t see how that breastmilk would be “best”. In addition, I was present for nearly every conversation between her and the lactation consultant and never once did the lactation consultant or nurses try to talk to her or encourage her to make better nutritional choices for the benefit of her baby (let alone herself).

    The subject of breastfeeding is one I follow closely and appreciate the thoughts and research behind this article. My thoughts are just my own and having read this article I thought maybe I could “safely” share them. Thank you.

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  9. Thanks for this thought provoking article. You ask what the perceived barriers are to breastfeeding and how your readers think they can be addressed.

    The Alberta Breastfeeding Committee is a not-for-profit society committed to protecting, promoting and supporting breastfeeding in Alberta. What is our answer to your question?

    We think adopting a health promotion approach based on the Ottawa Charter, and the Baby-Friendly Inititiave will move healthcare workers, governments, employers, and society in general to an understanding of the risks of not breastfeeding and improved support for those women who decide to breastfeed.

    Here is a link to paper outlining the tenets of the Ottawa Charter as well as a sheet created by the Alberta Breastfeeding Committee on what we believe is one major barrier to breastfeeding—lack of adherence to the International Code of Marketing of Breastmilk Substitutes and relevant WHA Resolutions. (links)

    Please see our website at to review some of our recent work as well as information about our annual conferences in Calgary/Edmonton venues September 27th and 28th 2012.

    Jodine Chase
    on behalf of the Alberta Breastfeeding Committee

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